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9255517888 Line 1 09:25:44 041'-ml O f` I>,3/E <br /> niz <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APR 2 0 2015 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER\nCEA VINTA!. <br /> � r7� AAC111T <br /> SERVICE STATION El <br /> OWNER I OPERATOR <br /> West Valley Chevron CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME 8363464 <br /> SITEADDRESS 2615 WestGrantline Road Tracy 95304 <br /> Street Number Direction Street Name eft Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6805 Sierra Court,Suite G <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> Dublin CA 94568 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 408 ) 636-6651 Z I ZZ %) <br /> PHONE#2 EXT BOS DIS CT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LIDDYMCKENZIE CHECK if BILLING ADDRESSIZ <br /> BUSINESS NAMEPHONE# EXT• <br /> Gettler Ryan Inc. 408 636-6651 <br /> HOME or MAILING ADDRESS FAx# <br /> 6805 Sierra Court,Suite G ( 408 ) 551-7888 <br /> CITY Dublin STATE CA Zip 94568 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that therk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL s. <br /> APPLICANT'S SIGNATURE: DATE: Z-011 <br /> PROPERTY/BUSINESS OWNER❑ OPEf ANAGER 1:1 OTHER AUTHORIZED AGENT pr Agent for Owner <br /> IfAPPLICANT is not the BILL �PAR7Y.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. pq <br /> TYPE OF SERVICE REQUESTED: SB989Repair/Retest FCC- yr T <br /> COMMENTS: ,?0 <br /> REPLACE ELECTRICAL CONDUIT PENETRATIONS IN VENT BOX AND UDC'S. NJOAgUAi c S <br /> ACCEPTED BY: b 1 V 6 EMPLOYEE#: DATE: 4_zo - / <br /> ASSIGNED TO: Hem Y� EMPLOYEE#: DATE: Lf -'u1 /� <br /> � <br /> Date Service Completed (if already Completed): SERVICE CODE: I ci� P/E: <br /> Fee Amount: , Amount Pall390 C�C7 Payment Date <br /> Payment Type Invoice# ShAw# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Received Time Apr. 20. 2015 9: 14AM No- 8549 <br />